Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities. Started 11/28/08. I hope you find it useful; if so, consider signing up as a "follower".

Wednesday, March 31, 2010

.The New York Times on March 28, 2010 had a front-page article on the Seder planned at the White House for this year, apparently the second annual one (not counting the impromptu one during the campaign two years ago) – “Next year in the White House: a Seder tradition” by Jodi Kantor. I became a little teary reading it, but I tend to do that about things that are about bringing people from different backgrounds together, sharing, and finding common-ness. Just as I tend to get furious and angry about those who sow distrust, difference and divisiveness. I was going to say “sow hate”, but it’s hard to attack people and say you’re against hate, although it is their hatred I abhor.

The Seder is the celebration of Passover, marking the story of Exodus, the liberation of the Jewish people from slavery in Egypt. Its significance for African-Americans who were in slavery in this country is obvious, and was obvious to the slaves who were being converted to Christianity and learning this story as they suffered in bondage; many of the spirituals they created used the thinly-veiled metaphor of the Israelites in captivity. Thus it should not be surprising that it is the first African-American President who brings the Passover tradition of the Seder to the White House, or that it is attended by “mostly Jewish and African-American guests”. Nor is it surprising that the event is a “ritual that neither the rabbinic sages nor the founding fathers would recognize.” Hopefully this will not matter to those Jews who observe the Passover with the fully religious celebration, although it may offend some of those who are interested only in division and distrust. I was once warned, on being invited to a Seder, that this was a “Jewish” holiday, and that the host would not enjoy bringing in references to those “others”.

At least that host was aware that many people do. It was certainly true in the secular tradition in which I was raised, in which Passover, not Rosh Hashanah or Yom Kippur which are the High Holy Days of the Jewish religion, was the main holiday precisely because it honored liberation and appealed to larger human hopes. It was true of our Seders, in which “Go Down, Moses” was as integral a tune as “Dayenu”. In addition to remembering the enslavement of Jews and African-Americans, remembrance of the Holocaust was of course central, with particular focus on the Warsaw Ghetto Uprising* of 1943 (a 40-day armed resistance to Nazi deportation of Jews from the Ghetto, the final episode beginning with a Nazi attack on Passover eve), was a part of our Seder having occurred not very long in the past. In modern secular Seders, the plight – enslavement, genocide, torture, especially when it is conducted by religion or ethnicity or gender or race or sexual orientation – is remembered and condemned.

Of course, the story of the Exodus is also a story of ethnic exceptionalism – the name of the holiday comes from the story that the Angel of Death “passed over” the houses of the Israelites, smeared with lamb’s blood, as he systematically killed the first-born son in the house of the Egyptians. But it is the story of the liberation, of the undying hope for freedom in the human spirit, that is its most important characteristic, that resonates most for me and many others (possibly including those at the White House Seder). In a world of individualism, group-ism, exceptionalism, it is important that we remember that we are all people, and all in it together.

“In the end, of course, who he was is not that significant —nor, for that matter, which nation issued his passport. National identities were of little importance in the Spanish Civil War. The almost 40,000 volunteers resisted being singled out as heroes; they had joined an international, multi-ethnic and multi-racial coalition because they believed fascism was a global threat that demanded international solidarity, and they went to Spain despite the fact that many foreign governments opted for non-intervention.”

On the blog page I ask “Could there be anything more beautiful?” I mean not only the fight against fascism, but at a deeper level: Can we maintain our own identities and traditions but understand that, at our core, we are the same?

*Many of the links are to Wikipedia entries, because they are well-know and easily accessible. There are much better and more authoritative sources, however, for spirituals, the Warsaw Ghetto Uprising, the Spanish Civil War, and the other links.

Saturday, March 27, 2010

.I’m a doctor, so maybe I have a different take on this than other people, but somehow I don’t think so. I would imagine most folks would want to know, before being put on a new, expensive medication (and in medications, “new” virtually always = “expensive”) a little more about it than that it worked better than nothing, or a placebo (which is not always the same thing, given the “placebo effect” – folks sometimes improve somewhat if they think a drug is going to work). I would imagine they’d want to know that it works better than, or as well as, or at least almost as well as, the drug that they are taking, or another drug, or especially a long-established, effective, we-know-how-well-it-works-and-the-side-effects-too, and frequently generic and cheaper, drug.

Studies that do this are called “comparative effectiveness research” (they can also be used for devices and other treatments). You would think, then, that there would be consensus that a new drug should be tested against existing drugs for the same condition and shown to be superior, or at least (in the scientific parlance) “non-inferior”. Not true; the FDA just requires studies that show it is better than placebo. This issue has been getting a lot of attention in the medical and scientific communities recently. A major contribution to this discussion was the recent study published by Michael Hochman and Danny McCormick in JAMA, March 10, 2010, “Characteristics of published comparative effectiveness studies of medications” (JAMA. 2010 Mar 10;303(10):951-8). This study looked at 328 previous studies evaluating medications and found that less than a third (104) had compared the drug against something other than placebo. Only 11 compared the drug against non-drug (“non-pharmacologic”) treatments; among the others only 45 compared two or more drugs, 32 with different pharmacologic “strategies”, and 16 different dosing schedules. Most of these, 90 of the 104, were financed by non-commercial sources (e.g., the government); the placebo studies were almost all funded by pharmaceutical manufacturers, who fund, it should be noted, more than half the medical research done in this country. This would be a good and noble thing, were it not actually a self-serving and thus often bad thing. Since many people cannot access the JAMA article (and might find it harder to understand it anyway), Hochman and McCormick also published an op-ed piece in the Los Angeles Times, “Medicine in the dark” which is clear and persuasive. In the same JAMA issue, two HHS physicians, Patrick Conway and Carolyn Clancy (who is head of the Agency for Healthcare Research and Quality, AHRQ, that supports much comparative effectiveness research), comment on the Hochman and McCormick article and call for increased comparative effectiveness research (“Charting a path from comparative effectiveness funding to improved patient-centered health care”, JAMA. 2010 Mar 10;303(10):985-6). They do not comment on the pharmaceutical industry funded studies.

Most practicing physicians are not active clinical researchers, and even those who are usually have a very limited research focus. Therefore, physicians need access to accurate and unbiased research, and need to spend the time keeping up with important new information that may impact your care. (By “important”, here I mean something that actually may benefit your health or that of another patient, not something that may benefit the bank accounts of the drug company shareholders – which I am sure is important to them.) Before beginning you on a new drug for your condition, especially when it is more expensive – often very much more expensive – and newer (please note that with drugs “newer” does not always – in fact, uncommonly, mean better. It does, however, virtually always mean “used and tested less so we are not necessarily aware of all adverse effects”, so you would hope that your doctor had reason to believe it was going to work better (or at least not worse) for you than your old treatment, and that this belief was based on independent reliable sources. That is, if not the original research, at least on independent reviews and summaries (like that of Hochman and McCormick, or The Medical Letter), and not simply information provided to them by drug salesmen. If you see lots of pens, pads, clocks, and other doodads with pharmaceutical company logos in your doctor’s office – not to mention if you get those neat “free samples” (which are never free; you and others buying the drug eventually pay for them) of the newest, most expensive drugs being pushed by the drug companies, you might begin to get suspicious. You might even ask your doctor how much time s/he spends with drug company reps and how much of his/her information comes from them, and has s/he ever audited his/her charts to actually find out (whatever s/he believes) if s/he is prescribing more of drugs pushed by drug reps? You might even complain. Doctors are sensitive to their patients’ complaints.

But what about when the doctor does look at the original research, but the research itself is largely funded by drug companies, who frequently suppress negative results? And if, as Hochman and McCormick point out, most of them just compare the new drug to placebo, not other established treatments? What value is there in that? Well, Peter Pitts, interviewed on NPR’s Morning Edition in their story on this issue on March 10, 2010, thinks there is value. He says doctors need to know what options are available. Of course, Mr. Pitts is a spokesman for the Center for Medicines in the Public Interest, a group whose name is absolutely contradictory to its function, since it functions in the interest of the pharmaceutical industry, which funds it. (And, really importantly, should never be confused with the absolutely wonderful Center for Science in the Public Interest, a truly great public interest organization that interprets research and advocates for food safety, the environment, and other issues that we need real scientists to help us to understand.)

As a physician, I agree with Mr. Pitts that we need to know what options are available. And, apparently unlike Mr. Pitts and the industry he represents, I think we need to know the whole story and how those options compare to one another, not a placebo. And I think you would want your doctor to know that also..

Sunday, March 21, 2010

.In their New York Times article on March 1, 2010, about “Doctors without Morals”, Leonard S. Rubenstein and Stephen N. Xenakis contrast the investigation into the Bush administration lawyers involved in the authorization of torture (who they feel were let off much too easily, with an assessment of “poor judgment”, not professional misconduct) with the complete lack of investigation into the doctors and psychologists who participated in the torture itself, as well as the CIA’s Office of Medical Services that investigated the activities when they were questioned by the agency’s Inspector General, and found that, well, everything was ok.

“According to Justice Department memos released last year, the medical service opined that sleep deprivation up to 180 hours didn’t qualify as torture. It determined that confinement in a dark, small space for 18 hours a day was acceptable. It said detainees could be exposed to cold air or hosed down with cold water for up to two-thirds of the time it takes for hypothermia to set in. And it advised that placing a detainee in handcuffs attached by a chain to a ceiling, then forcing him to stand with his feet shackled to a bolt in the floor, ‘does not result in significant pain for the subject.’” Waterboarding, when limited to “12 applications over two sessions within 24 hours, and to five days in any 30-day period,” was ok.

The questions is “Who are these people? Other questions, such as “How did they get to be doctors?”, “How can they sleep at night?”, “How can they have been put in charge of this?”, and “How come they still are allowed to practice medicine?” Most important is “Why was there no investigation?” Doctors are investigated by their state licensing boards and others all the time. They can lose their licenses for minor drug offenses, and are subject to severe restrictions and monitoring for risky behaviors involving drugs or alcohol, even if no actual patient was hurt (yet). They can be, and are, sued for all sorts of things, sometimes real malpractice, sometimes in the hope, by patient and lawyer, that they or their insurance company will agree to a monetary settlement in order to avoid the time, pain, and expense of a trial, even when they are not guilty. They are subject to fraud investigations by Medicare, sometimes found liable for honest mistakes.

But actually condoning and designing and implementing torture on actual people with actual damage? Apparently, if done by the CIA, not even worthy of investigation. It is absolutely intolerable and outrageous. Another question is “how did people get this way?” Are they born without moral compass? Were they ethical health professionals who just got so carried away by being part of the CIA that they lost their way? Is the role of the Office of Medical Services particularly despicable because it involved time and thought and did not occur in the health of the moment? I think another question we have to ask is whether we have tolerated less severe moral lapses in physicians that have made this a slippery slope rather than a fall off a cliff.

Where is the dividing line between ethical and unethical behavior in physicians and other health professionals? Clearly, to most of us, it lies somewhere this side of doing or condoning torture (except to the folks involved in the torture directly, in the Office of Medical Services who ok’ed it, and in the licensing and disciplinary boards within and outside of government who have not investigated). But what about facilitating and performing capital punishment? All reputable medical societies say it is unethical for physicians to be involved, but obviously the government authorizes and pays those who do. What about taking bribes from drug companies for using and endorsing their products? The issue of physicians’ conflict of interest has certainly been in the news, but bribes? Well, if I’m a realtor who gives you a present for having listed your house with me, that isn’t a bribe, since it is your money at risk. If I am a company who gives you, as a legislator, money for voting on a public works project that benefits the company, that is a bribe, since it involves the public’s money for which you have fiduciary responsibility, not your own. I would suggest that pharmaceutical and medical device companies give gifts to physicians not so they individually will use their products, but so they will recommend, or even more actually prescribe them, to patients. This is a bribe.

What else besides gifts from drug and device makers, from pens to large corporate board fees, from free samples to tips to resorts, might challenge the morality of physicians?

And, in the particular case of the torture-doctors: Rubenstein and Xenakis say, “This is an unconscionable disservice to the thousands of ethical doctors and psychologists in the country’s service. It is not too late to begin investigations. They should start now.”

Wednesday, March 17, 2010

.This powerful piece was written by Robert Ferrer, MD, MPH, who has previously written guest blogs. It is too bad that the pundits and policy wonks will not see it.

On any given day there are five to ten of them on our hospital service. In the room that our clinical team uses to discuss patients we reserve one of our two white boards just for them. As a group they are defined by three characteristics: they have suffered from diabetes for many years, they have lacked steady health insurance and medical care, and they are in various stages of dismemberment. Uncontrolled diabetes has damaged their blood vessels, and the ensuing gangrene or bone infections brings them to our hospital, where we care for their medical problems while the surgeons amputate toes, feet, or lower legs. The patients often lose these parts in sequential episodes as their circulation worsens and the complications progress.

Most are men, and many of them are younger than you would expect, in their late thirties or early forties. Almost all have been recently working, though the operation they now require will usually end their employability in the blue collar jobs they occupy. When we ask when they last received regular care for their diabetes, the only mystery is where they*ll fall in the range from "a year ago" to "never". And therein lies what makes these complications especially sad, because with patient education and periodic low-tech evaluations, most of the amputations could have been prevented.

The fact that they are so often not prevented emerges from an unhappy synergy between two epidemics: diabetes and uninsurance. Among large American cities, San Antonio ranks near the top for both; a quarter of its residents lack health insurance and about 1 in 10 have diabetes, though in the less affluent parts of town the diabetes statistic is closer to 1 in 4. Being poor puts one at risk for both diabetes and being uninsured, but being poor in particular locales is especially risky. What those locales share is stingy public insurance programs, (for example, the earnings ceiling above which adults with children no longer qualify for Texas Medicaid just 26% of the federal poverty level -- about $5200 for a family of four -- and, as in most states, childless adults without disabilities don*t qualify at all), and many jobs that don*t come with health insurance. In many cities, as in ours, a large number of undocumented immigrants also add to the number of uninsured.

So there are three of the big conundrums of national heath care reform: the scope of public insurance, expanding coverage under private sector insurance, and what should be done about non-citizens. (A fourth, costs, will come up later). Framed in this way, as bloodless policy questions far removed from the daily realities of the ward, the urgency is drained out of them. Raised yet another level of abstraction higher -- Socialism! -- the debate becomes an absurd joke, the cruelty of which will be felt by those who will needlessly lose limbs in the coming years if reform fails yet again.

For the patients who occupy the beds on our wards -- high-risk people in low-benefits occupations living in a low-services state -- the list of responsive policy options seems very narrow. The realistic options are heavily regulated public or private plans based on large risk pools and with adequate subsidies to ensure that cost is not a barrier to regular care. Less important than the exact mechanism, however, is that there be a path to coverage short of losing a leg, becoming disabled, and qualifying for coverage through disability benefits. As for the non-citizens, our county decided in 1997 to respond to the compelling local needs by creating a publicly funded plan that allows the working poor to access full-spectrum health care on a sliding repayment scale. Hard-liners may balk at reform that even considers these types of arrangements, but what is the alternative? Deporting people with gangrenous limbs or failing kidneys? Continuing to provide only expensive, last-minute rescue care?

Although we have much yet to learn about controlling health care costs, one clear message is that preventing complications among high-risk patients with chronic disease will yield important savings. A typical hospital bill for a diabetic patient having an amputation runs to $10,000 or $20,000 or more, not because of the surgeon*s fee, but because the patients* other diagnoses, often including antibiotic-resistant infections and failing kidneys, complicate their treatment. Investing in access and regular care before a crisis occurs saves money - as well as limbs, kidneys, and hearts.

Meaningful reform cannot be postponed any longer. George Orwell wrote that in political discourse, *words fall upon the facts like soft snow blurring the outline and covering up all the detail.* Through the seasons of debate, the the urgent needs of those suffering for lack of care have been buried beneath the snow of words. But those needs are still there, regardless of the political calculations. To pretend that there is not a way forward to a workable conclusion coldly discards the opportunity to ease the suffering for millions of our people. If that happens, many will feel the metaphorical phantom pain of another lost opportunity for reform. And a smaller subset of the vulnerable among us will experience the real thing. .

Saturday, March 13, 2010

.The New York Times, March 7, 2010, (US enriches companies defying its policy on Iran, by Jo Becker and Ron Nixon) reveals that the US is supporting, primarily through government contracts, many companies that are involved in doing business in and with the government of Iran, a country that official US policy is to discourage companies from doing business with. Moreover, most of these corporations are doing business in the energy (especially gas and oil) sector, which is not a surprise given that Iran is a big oil producer, and also in supplying the technology for, say, developing nuclear power. Or nuclear weapons. A bunch of politicians are now posturing about this (after all, Iran is a fundamentalist Islamic state that is led by a Holocaust-denier who routinely attacks the US that many think is in the process of developing nuclear weapons), but we will see what, if anything, will happen.

So, maybe it is upsetting, but it is scarcely surprising. The US government supporting the interests of big multi-national corporations even when they are operating against the interests of the American people? If this is a shock to you, where have you been? We (the US, the world) are in the middle of (despite the pronouncements that we are “coming out of”) an enormous financial crisis brought about by the overt support by the US government of policies based upon supporting the unmitigated and unencumbered greed of the financial industry. And those policies, which have included trillions of dollars in bailouts of those companies, continue essentially unimpeded. If anyone is “coming out of” the financial crisis, it is those who brought it on, happily and blithely making their millions and billions again while a huge percent of people even in the US are unemployed, working in poor-paying jobs, and have no reasonable prospect of finding the kind of job that allows the dignity of supporting your family, having good food and a good home, sending your kids to college, and expecting a reasonable retirement. And, oh yes, having health care. The breadth of this crisis is spread wide, but those who were already poor and on the edge, disproportionately although scarcely only racial and ethnic minorities, have of course been the hardest hit. This is no joke and has people angry, angry at the financiers and angry at the government that has talked tough but not “walked the walk”. Democrats have a lot of blame, from the Clinton era policies to those of Obama and his recycled-Clinton financial advisors, but it is absurd for that criticism to be coming from Republicans. Not only was the Bush-era so aggressive in its de-regulation and support of the financial industry (and the energy industry currently involved in Iran) that it makes Clinton and Obama look good by comparison, but even now the Republicans in Congress are pushing policies that would make it even worse than those of the Administration. And that is not easy.

In health care, often the subject of this blog, the insurance industry is getting attacked. The President’s speech indicted them 13 times. But they are still there, they are still making billions in profits, and we still have at least 75 million people who are uninsured or seriously underinsured (and most of the rest of us who will find out when we get sick!). In response to great pressure, Anthem Blue Cross of California* (let’s not forget who the bad guys are!) withdrew, at least temporarily, its planned up-to-39% rate increases, but these guys are not going bankrupt, they are still making a fortune. It would not be too far-fetched to suggest that they proposed this just so they could roll it back, and make it look like they gave something up, in order to prevent people and regulators from demanding that they give up some of what they currently have. It wouldn’t be too far-fetched, but it probably underestimates their greed; I expect to see quieter efforts to increase rates return soon.

We have a conflict here. Politicians, Democratic and Republican, want to condemn the excesses of powerful corporations while continuing to take their money. Regular people, including me and a lot of teabaggers, believe the solution should be that portrayed by Wiley Miller in the March 7, 2010 comic “Non Sequitur”. (Check it out.) Somehow, we are being hosed; by the financiers, by the energy companies, by the insurance companies. (On the latter, and while we’re on comics, see “Shoe”, Thursday, March 11, 2010.)

Why would I be surprised?

*”Anthem” is the name that Wellpoint, the stock exchange-listed holding company, uses for the for-profit BlueCross/Blue Shield plans it owns, such as the one in California. Not all BC/BS are for-profit; many remain not-for-profit (e.g., BC/BS of Kansas, based in Topeka, KS, whose planned sale to Anthem was, I have previously noted, blocked by then-Insurance Commissioner Kathleen Sebelius in 2002, and BC/BS of Kansas City, based in KC, MO.) Unfortunately, market competition often has the not-for-profits behaving almost as badly, in terms of exclusions and rate hikes, as the for-proftis..

Friday, March 5, 2010

This guest piece, by Robert Bowman, MD, of the AT Still School of Osteopathic Medicine in Mesa, AZ, can be considered to be a sequel to his guest blog from January 15, 2009, Ten Biggest Myths Regarding Primary Care in the Future. In that piece, Dr. Bowman discussed how, of the five primary care training “forms” (General Pediatrics, General Internal Medicine, Family Medicine, Nurse Practitioners and Physician assistant) only family physician provided enough “Standard Primary Care Years” per graduate, and distributed to the areas in which people live, to provide sufficient primary care. In this piece, he presents information on how the change in the workforce is likely to have an even greater impact on subspecialists.I think that this is very timely. The idea that family physicians, or primary care doctors in general, will be “replaced” by nurse practitioners and/or physician’s assistants keeps rearing its ugly head despite evidence to the contrary. Dr. Bowman demonstrates that reimbursement policies that pay far more for “partialism” encourage both physicians and non-physicians to enter subspecialist practice. We still do and will need more primary care and it is not going to happen by magic. It is going to happen by changing reimbursement policies. (See, for example, Mary Carmichael's "The Doctor Won't See You Now", in Newsweek, Feb 26, 2010).

The first two graphics demonstrate trends in the number of primary care providers by "form" if there were not movement into subspecialism, and what the real trend will be.The final graphic compares the retention in primary care, over time, for the different "forms" based on whether they are more "permanent choice" primary care (e.g., family medicine) or "flexible choice" (e.g., internal medicine).

10. “Midlevel” Growth: Nursing leaders have promised to deliver health access where it was most needed and received numerous concessions to move beyond nursing but have largely left health access behind along with basic nursing. Nursing leaders continue to promise primary care while nurse practitioners steadily depart primary care to become specialty workforce and appear poised to become “nurse doctors” (DNPs). There is every reason to believe that DNPs will be no more – and probably less – likely to practice in underserved or rural areas at greater rates than current NPs. Physician assistant leaders are likely to follow the independent "successes" of nursing. Future subspecialist physicians will face competition no other physician subspecialists have ever had to face.

9. Increasing NP, IM, Ped entry into subspecialties. About 40% more nurse practitioner, 50% more internal medicine, and 60% more pediatric graduates are entering specialty workforce compared to a 10 - 15 years ago, and specialization rates have continued to increase. In addition, more internists and nurse practitioners convert from primary care to specialty care in the years after graduation.

8. Increasing PA production, also entering subspecialties. Over 220% more new physician assistant graduates are entering the sub-specialty workforce, increasing from fewer than 1500 in 1998 to over 4600 in 2008. The percentages in emergency care, orthopedic, and surgical subspecialties are now greater than those in primary care. Physician assistants also are converting from primary care to specialty care after graduation. Only 28% of 2008 graduates entered primary care in AAPA surveys.

7. Postive Cost-Benefit ratio for “midlevel subspecialists. Nurse practitioner and physician assistant graduates have lower employment costs than subspecialist physicians. It is possible for 2 or 3 NP or PA subspecialists to generate more revenue than one subspecialist physician for less cost of salary, benefits, and other physician perks.

6. Increased “midlevels” in subspecialties decrease need for more subspecialist physicians. More and better nurses, assistants, and other health care team members are recruited to subspecialty workforce because the higher reimbursement for subspecialty services as compared to primary care allows these subspecialists to pay them more. Physician assistants and nurse practitioners are on track to increase to 450,000 that are more than 70% subspecialty care. The US is moving to a specialty workforce that can deliver more specialty care with fewer specialty physicians.

5.Increasing US graduates likely will further increase subspecialist production. US graduates deliver twice the workforce of non-citizen international medical graduates due to delays in entry and departures from the US workforce after graduation. Expansions of US medical schools are likely to replace more non-citizens with US origin graduates. This replacement results in twice the specialty workforce for each position transitioned from a non-citizen to a US origin graduate.

4. Increasing subspecialist production of US Medical Schools. The United States produces 40 - 50% more subspecialist workforce from each type of medical school compared to a decade ago. Currently no one can estimate just how much specialty workforce will be produced as the annual graduates entering the workforce continue to increase with higher percentages found entering specialty care in physicians and in non-physicians.

3. Threats to very high subspecialist reimbursement. To the extent that there is any decrease in subspecialist reimbursement, these physicians will face the possibility of longer hours, more services, less vacation, and more years of work per subspecialist physician.

2.Supply, demand, and cost of care. All physicians will be blamed for continued health care cost increases as all levels of government and all businesses and all of the US people pick up the tab. There is potential for even more costs with subspecialists increasing services to compensate for an oversupply of subspecialists.

1. And, finally, when the United States finally invests in sufficient primary care substantially fewer visits will be needed in specialty offices.

Add to this· the steadily increasing disconnect between subspecialist physicians separated from their patients by additional assistants· the admission patterns of medical schools favoring upper-income students leading to subspecialists with ever more exclusive origins who are less and less like lower and middle income Americans .

In other words, our medical education leaders and medical association leaders and subspecialists......will probably never see it coming.